Abstract
Objective: Ruptured dissecting aneurysms of the intracranial vertebral arteries exhibit an extraordinarily high risk for morbidity and mortality and are prone to re-rupture. Therefore, early treatment is mandatory to induce stagnation of the critical dynamic mural process. Appropriate endovascular approaches are segment sacrifice and reconstruction, however, both carry specific risks and benefits. To date most studies discuss only one of these approaches and focus on one specific device or technique. Therefore, our study aimed to present our experiences with both techniques, providing a considered approach on when to perform endovascular reconstruction or sacrifice.Materials and Methods: We retrospectively reviewed patients with subarachnoid hemorrhage in our database, suffering from dissecting aneurysms of the intradural vertebral arteries and treated endovascularly in the acute setting. A total of 16 cases were included. Clinical history, radiologic findings and outcomes were analyzed.Results: In 7 patients a reconstructive approach was chosen with 4 of them receiving stent-assisted coiling as primary strategy. One of the 7 patients suffered early re-bleeding due to progression of the dissection and therefore treatment was augmented with implantation of 2 flow diverters. The remaining 2 patients were primarily treated with flow diverters in telescoping technique. In 9 patients a deconstructive approach was followed: 6 patients were treated with proximal coil-occlusion of the V4 segment, 3 patients received distal coiling of the V4 segment. Two patients died (GOS 1) in the subacute stage due to sequelae of recurrent episodes of raised intracranial pressure and parenchymal hemorrhage. Two patients kept severe disability (GOS 3), six patients had moderate disability (GOS 4) and seven patients showed full recovery (GOS 5). None of the patients suffered from a procedural or postprocedural ischemic stroke.Conclusions: In patients with good collateral vascularization, proximal, or distal partial segment sacrifice via with endovascular coil occlusion seems to yield the best risk-benefit ratio for treatment of ruptured dissecting V4 aneurysms, especially since no continued anticoagulation is required and possibly essential surgery remains feasible in this scenario. If possible, PICA occlusion should be avoided—although even proximal PICA occlusion can become necessary, when weighing against the risk of an otherwise untreated ruptured V4 dissecting aneurysm. Contrarily, if the dominant V4 segment is affected, the hemodynamic asymmetry prohibits occlusion and necessitates reconstruction of the respective segment. For this, implants with high metal coverage treating the entire affected segment appear to be the most promising approach.
Highlights
Arterial dissections in the domain of the vertebrobasilar territory are an overall rare but important cause for ischemic and hemorrhagic stroke in young patients [1]
Accidental intimal damage subsequently allows blood to enter the vessel wall with high velocity and pressure, dissecting the wall along its layers, resulting in the formation of a false lumen or intramural hematoma [4]. Depending on their exact localization and extent vertebral artery dissections may very rarely occur without apparent symptoms, infrequently manifest as subarachnoid hemorrhages but mostly cause neck- and occipital pain, which is frequently followed by posterior circulation stroke [5]
After thorough review of clinical and radiological data, 16 patients were identified with acute subarachnoid hemorrhage (SAH) from vertebrobasilar dissecting aneurysms
Summary
Arterial dissections in the domain of the vertebrobasilar territory are an overall rare but important cause for ischemic and hemorrhagic stroke in young patients [1]. Accidental intimal damage subsequently allows blood to enter the vessel wall with high velocity and pressure, dissecting the wall along its layers, resulting in the formation of a false lumen or intramural hematoma [4] Depending on their exact localization and extent vertebral artery dissections may very rarely occur without apparent symptoms, infrequently manifest as subarachnoid hemorrhages but mostly cause neck- and occipital pain, which is frequently followed by posterior circulation stroke [5]. If the intimal tear primarily affects the intracranial segment or continues intra-cranially through the dural entry point and further extends sub-adventitially, a dissecting aneurysm evolves and may rupture primarily or secondarily, leading to subarachnoid hemorrhage (SAH) [9] Mortality in these patients can be dramatically high, with rates up to 83% [10]. As a consequence, dissecting aneurysms of the intracranial posterior circulation must be treated interventionally as fast as possible to prevent further hemorrhage and the higher morbidity associated with repeat rupture
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